Leadership and Management - U World
The nurse is caring for a client in soft wrist restraints. Which tasks can the nurse safely delegate to the unlicensed assistive personnel? Select all that apply. 1. Assist the client with using a bedpan 2. Check pulses and sensation of extremities 3. Observe skin for signs of impairment 4. Perform range of motion exercises 5. Turn and reposition the client in bed
1. Assist the client with using a bedpan 4. Perform range of motion exercises 5. Turn and reposition the client in bed Nurses may delegate to UAP tasks that relate to basic hygiene; tasks of daily living; measurement and documentation of vital signs and intake and output; and validated technical skills. Activities requiring assessment may be performed only by the nurse
The nurse supervisor tells the psychiatric nurse to go to the telemetry unit ("float") as the unit is short staffed and has 2 clients with cardiac arrest. The nurse is not familiar with this client population and does not want to go. What is the best response by the psychiatric nurse? 1. Clarify the skills/knowledge that the nurse is able/unable to perform 2. Read the policy and procedure book for the unit before providing care 3. Refuse to go due to concerns about client safety 4. Tell the supervisor to send someone else instead
1. Clarify the skills/knowledge that the nurse is able/unable to perform When a nurse is asked to care for clients in an unfamiliar population ("float"), the duties to be performed and the nurse's limitations in skills or knowledge of specialized care should be clarified. Refusing to go can result in disciplinary action, including termination.
A visiting family member of a hospitalized client reports sudden onset of a headache and numbness in half of the body. The visitor asks the nurse to take a blood pressure reading. What is the most appropriate response by the nurse? 1. Encourage the visitor to lie down to see if symptoms change 2. Initiate protocol to assist the visitor to the emergency department 3. Proceed to take the visitors blood pressure 4. Suggest that the visitor call the health care provider
2. Initiate protocol to assist the visitor to the emergency department Providing care established a legal caregiver obligation/relationship between the nurse and a visitor. In the event of a visitor emergency, the nurse should refrain from actions that establish this relationship and instead implement facility protocol to help get the visitor promptly to the emergency department
The nurse witnessed a signed informed consent for a inguinal hernia repair surgery. During the procedure, the surgeon discovers a secondary ventral hernia that also requires repair. Which action should the nurse perform? 1. Add the secondary hernia to the consent form that the client signed before the procedure 2. Call the client's medical power attorney to provide consent for the additional procedure 3. Document that an additional hernia was found and that it will require surgery at a later time 4. Witness an additional consent after both procedures are complete ad the client is awake
2. Call the client's medical power attorney to provide consent for the additional procedure Informed consent is required before an non emergency procedure. If the need for an additional procedure is discovered during surgery, the client's medical power of attorney, legal guardian, or next of kin should be contacted to provide consent.
Which client assignment is most appropriate for the nurse on an orthopedic unit to assign to a float nurse from a general medical unit? 1. Client 1-day postoperative with external fixators to stabilize a complex fracture of the wrist 2. Client 3 days post-knee replacement surgery awaiting discharge 3. Client who is scheduled for an above-the-knee amputation today 4. Client with a long leg cast applied yesterday morning to treat a fractured ankle
4. Client with a long leg cast applied yesterday morning to treat a fractured ankle The nurse on the orthopedic unit who is giving client assignments to a float nurse, must consider how to best meet the needs of the clients safely. The most appropriate assignment is a stable client, who requires basic pain, peripheral, and neurovascular assessments, which should be familiar to a float nurse from a general medical unit.
The nurse is delegating client care tasks to an LPN and UAP. Which of the following assignments are most appropriate to assign to the LPN? Select all that apply. 1. Administer a client's daily dose of subcutaneous insulin glargine 2. Administer a scheduled oral analgesic to a 2 days postoperative client 3. Complete an admission nursing interview for a client admitted for elective hysterectomy 4. Reinforce teaching on self-administration of insulin to client with diabetes mellitus 5. Tally the shift's intake and output for the entire unit
1. Administer a client's daily dose of subcutaneous insulin glargine 2. Administer a scheduled oral analgesic to a 2 days postoperative client 4. Reinforce teaching on self-administration of insulin to client with diabetes mellitus Nurses preparing to delegate client care should consider the 5 rights of delegation. Appropriate tasks to delegate to an LPN include administration of oral and enteral medications, excluding iV route, and reinforcement of teaching previously provided by the registered nurse
A male client has terminal metastatic disease. He arrives at the emergency department with respirations of 6/min and an advance directive indicating to withhold resuscitative efforts. What should the nurse's response be? 1. Apply oxygen at 2 L by nasal cannula 2. Ask the client if her wants to change his mind 3. Ask the spouse what she wants done 4. Determine who has medical power of attorney
1. Apply oxygen at 2 L by nasal cannula Advance directives include a living wil or a medical power of attorney. The client's wished should be honored.
The nurse is assigned to care for clients with assistance from UAP. Which of the following tasks are appropriate for the nurse to assign to UAP? Select all that apply. 1. Emptying a urinary drainage bag and recording output volume 2. Emptying and verifying the patency of an accordion drain 3. Escorting a disgruntled family member off the unit 4. Providing perineal care around an indwelling urinary catheter 5. Reapplying bilateral sequential compression devices
1. Emptying a urinary drainage bag and recording output volume 4. Providing perineal care around an indwelling urinary catheter 5. Reapplying bilateral sequential compression devices Emptying a urinary drainage bag, providing perineal care around an indwelling catheter, and reapplying sequential compression devices can be performed safely by UAP. Assessing the patency of a wound drain is the responsibility of the registered nurse, and disgruntled visitors should be escorted off the unit by security.
The nursing team consists of a registered nurse (RN), licensed practical nurse (LPN), ad 2 unlicensed assistive personnel (UAP). The nurse considers the assignment appropriate if the LPN is assigned to care for which pediatric client? 1. A 1-day-old with tracheoesophageal fistula scheduled for surgical repair today 2. A 6-month-old who had diaphragmatic hernia repair 5 days ago 3. A 12-year-old newly admitted with productive cough and white blood cell count of 15,000/mm^3 4. A 16-year-old admitted for uncontrolled diabetes experiencing Kussmaul breathing
2. A 6-month-old who had diaphragmatic hernia repair 5 days ago The RN should delegate stable clients with expected outcomes to the LPN. The RN cannot delegate any techniques or procedures that involve evaluation, teaching, or assessment methods.
The registered nurse is caring for multiple clients on a medical-surgical unit and has finished the morning assessment. Which task is appropriate for the nurse to delegate to UAP? 1. Apply a collagenase dressing to a client's pressure ulcer for wound debridement 2. Assist a client 1 day postoperative hip fracture repair to the bathroom 3. Feed a client through a gastrostomy tube after elevating the head of the bed 4. Offer orange juice to a client if the blood glucose level is <70 mg/dL
2. Assist a client 1 day postoperative hip fracture repair to the bathroom The registered nurse may delegate components of care but not parts of the nursing process itself (eg. assessment, planning, evaluation, nursing judgment)
While reviewing prenatal records with a client and her partner, the nurse notes documentation in the medical record indicating that the client is a G2P0. However, the client denies a previous pregnancy. Which action by the nurse is appropriate? 1. Adjust documentation to indicate that the client is G1P0 2. Ask the client and partner about a previous miscarriage or abortion 3. Confirm the obstetric history when the client is alone 4. Explain the importance of accurate information to the client and partner
3. Confirm the obstetric history when the client is alone The nurse should be cautious of discussing a client's obstetric history in front of the client's partner or family to avoid breaching confidentiality. Clarification or further questioning about the client's history should take place when the client is alone
The charge nurse on a medical unit assignments for the nursing team composed of a registered nurse (RN), 2 licensed practical nurses (LPNs), and a student nurse (SN). Which assignment is the most appropriate? 1. LPN assigned to a client with a GI bleed and hypotension who is receiving blood and requires vital sign monitoring every hour 2. LPN assigned to a newly admitted client with a bowel obstruction who is experiencing severe abdominal pain 3. RN assigned to a client with a change in mental status who is being transferred to the intensive care unit 4. SN assigned to a client with multiple sclerosis and dysphagia who requires multiple oral and IV medications
3. RN assigned to a client with a change in mental status who is being transferred to the intensive care unit The more experienced RN is assigned to the client with more complex needs that require more advanced level of nursing skill and judgment. LPNs can perform noninvasive interventions and certain invasive tasks for more stable clients
The unlicensed assistive personnel (UAP) notifies the charge nurse that the client told the UAP that the client is feeling short of breath. What should the charge nurse do first? 1. Activate a rapid response team 2. Ask the UAP to take vital signs and report back 3. Notify the client's assigned licensed practical nurse (LPN) to assess the client 4. Personally go and auscultate the client's lungs
4. Personally go and auscultate the client's lungs The nurse must assess the client personally (rather than delegating) when a potentially ominous report is made by a less-qualified staff member
During change-of-shift report, the nurse going off duty notes that the nurse coming on has an alcohol smell on the breath and slurred speech. What actions are most important for the nurse to take? Select all that apply. 1. Do not continue the handoff report with the oncoming nurse 2. Document the incident according to facility policy 3. Notify the charge nurse 4. Say nothing but watch for impaired behavior 5. Tell the oncoming nurse that he/she is not fit for duty
1. Do not continue the handoff report with the oncoming nurse 2. Document the incident according to facility policy 3. Notify the charge nurse A nurse who is impaired by alcohol cannot be given client responsibility. the recognizing nurse should notify the supervisor, document the incident, and not give client responsibility to the impaired nurse
The registered nurse (RN) is discussing care of shared clients with the licensed practical nurse. Which of the following clients require intervention by the RN? Select all that apply. 1. A client receiving a blood transfusion who reports severe anxiety and has blood pressure 90/60 mm Hg and pulse 110/min 2. A client receiving oral metoprolol whose heart rate has decreased to 60/min after administration 3. A client whose blood pressure decreased from 130/80 Hg to 110/70 mmHg following administration of 1mg hydromorphone IV 4. A client whose blood pressure was 90/65 mm Hg before prescribed oral nifedipine was administered 5. A client whose pulse increased from 70/min to 100/min after albuterol administration
1. A client receiving a blood transfusion who reports severe anxiety and has blood pressure 90/60 mm Hg and pulse 110/min 4. A client whose blood pressure was 90/65 mm Hg before prescribed oral nifedipine was administered Nurses caring for clients receiving blood products should immediately intervene upon signs of transfusion reaction (eg. anxiety, hypotension, tachycardia). Clients should be monitored for hemodynamic instability if blood pressure medications are administered during hypotension. Opioids may cause decreased blood pressure due to histamine release
The charge nurse supervising a graduate nurse would need to intervene when the nurse violates health information privacy laws with which action? 1. Accesses the medical record of a client not currently assigned, but previously cared for, to assess client improvement 2. Advises a client's transport technician, "This client has metastatic breast cancer and must be moved very carefully due to fragile bones" 3. Ask a client quietly, "When were you diagnosed with diabetes?" during admission assessment in a semiprivate room with the privacy curtain in place who is organizing paperwork to be included it he client's medical record 4. Explains the results of a client's diagnostic testing to the unit clerk who is organizing paperwork to be included in the client's medical record 5. Writes a client's last name on w whiteboard hanging in the nurse's station on which scheduled procedures are logged
1. Accesses the medical record of a client not currently assigned, but previously cared for, to assess client improvement 2. Advises a client's transport technician, "This client has metastatic breast cancer and must be moved very carefully due to fragile bones" 4. Explains the results of a client's diagnostic testing to the unit clerk who is organizing paperwork to be included in the client's medical record Only health care personnel requiring health information to carry out their job duties should have access to or be advised of this information. Nurses, health care providers, and hospitals should take reasonable precautions at all times to safeguard client information
An unaccompanied 16-year-old girl comes to the emergency department with severe abdominal pain and vomiting. The client has a temperature of 102.2 F and a pulse of 120/min ad is lethargic. The client's parents are out of town, and no guardians can be reached. How should this client's care be handled? 1. Administer care until the parents or guardians can be reached 2. Admit the client but without giving care until the parents or guardians can be reached 3. Perform a pregnancy test to see if the client qualifies as an emancipated minor 4. Provide health care and follow up advice but do not give any direct care
1. Administer care until the parents or guardians can be reached. An underage client whose parents or guardians cannot be contacted and who needs emergency care should receive all necessary medical care until a parent or guardian can be reached to provide consent.
When caring for a client with pneumonia, which nursing activities are most appropriate for the registered nurse (RN) to delegate to the LPN working under supervision? Select all that apply. 1. Administering metered-dose inhaled medications 2. Monitoring lung sounds 3. Evaluating use of incentive spirometer 4. Nasotracheal suctioning to collect a sputum specimen 5. Teaching the importance of fluid intake
1. Administering metered-dose inhaled medications 2. Monitoring lung sounds 4. Nasotracheal suctioning to collect a sputum specimen The RN can safely delegate tasks to the LPN that do not involve the functions of high-level assessment, evaluation, or clinical nursing judgment
Which tasks can the registered nurse appropriately delegate to unlicensed assistive personnel? 1. Assist the registered nurse with ambulating a client 1-day post chest tube placement 2. Measure wound drainage from a bulb and document it on the flow sheet 3. Monitor for redness and swelling at the IV insertion site and report back to the nurse 4. Return an unused unit of packed red blood cells to the blood bank 5. Take family members to the waiting room after the client goes into surgery
1. Assist the registered nurse with ambulating a client 1-day post chest tube placement 2. Measure wound drainage from a bulb and document it on the flow sheet 4. Return an unused unit of packed red blood cells to the blood bank 5. Take family members to the waiting room after the client goes into surgery Unlicensed assistive personnel may perform clerical (eg. escorting family members, transporting blood products) and clinical tasks (eg. emptying, measuring, and recording output) related to the care of stable clients under the direction of the registered nurse
The charge nurse in the emergency department assigns a client to a new nurse who has been off orientation for a week. Which client assignment is most appropriate? 1. 3 year old with a temperature of 102.4 F who has a seizure at home 30 minutes ago and is very irritable 2. 8 year old with a closed fracture of the clavicle following a fall who is talkative and rates pain as a "2" on the 0-10 FACES scale 3. 32 year old with asthma who has an upper respiratory tract infection and a peak expiratory flow rate that is 45% of personal best 4. 72 year old prescribed antibiotics 3 days ago to treat acute sinusitis who reports shortness of breath and has a rash
2. 8 year old with a closed fracture of the clavicle following a fall who is talkative and rates pain as a "2" on the 0-10 FACES scale A new nurse should be competent in performing the basic skills needed to care for. alcient with a musculoskeletal injury
A client with end-stage renal disease, oxygen-dependent chronic obstructive pulmonary disease (COPD), and a Do Not Resuscitate (DNR) code status is admitted to the medical floor for COPD exacerbation. The nurse walks into the room and finds that the client is not breathing. What should the nurse do first? 1. Activate the code system 2. Call the HCP stat 3. Check the apical pulse 4. Check the blood pressure
3. Check the apical pulse A DNR order requires the nurse to withhold resuscitation in the event of a cardiac or respiratory arrest. If an event occurs, the nurse should assess for breathing and check the central or apical pulse. After performing these actions, the nurse should call the HCP to confirm the death.
Which of the following tasks would the charge nurse on a surgical unit assign to the experience UAP? 1. Assisting a client in ambulating to the bathroom for the first time following surgery 2. Explaining why using the incentive spirometer is important to a client with postoperative pneumonia 3. Feeding a client with dementia who has a blood sugar of 70 mg 4. Taking vital signs every 15 minutes on a client who was just transferred from the PACU
3. Feeding a client with dementia who has a blood sugar of 70 mg The RN can delegate routine tasks such as taking vital signs, supervising ambulation, making beds, assisting with hygiene, and ADLs to the experienced UAP. Assessment. analysis of data, planning, teaching, and evaluation are the responsibilities of the RN
The nurse is caring for 4-year-old child in the emergency department who has a 104 F (40 C) temperature, is obtunded, and has a positive Kernig's signs. The parents are refusing antibiotics and any treatment. The parents state that their religious belief is to trust in just prayer and believe the child will receive divine healing. What action does the nurse anticipate? 1. Assisting the parents in signing AMA papers 2. Discharging the child if parents have power of attorney papers 3. Notifying the hospital administration about the situation 4. Reassuring the parents that their decision will be respected under the principle of autonomy
3. Notifying the hospital administration about the situation Hospital administration will obtain legal protective custody of a minor child if the parents are deciding against life-saving measures for their child or when there is child abuse/neglect
The hospital nurse coming on duty notifies the unit of a delay due to a motor vehicle accident. The off-going nurse has an important appointment and must leave on time. How should the off-going nurse handle the situation? 1. Ask another nurse to watch the current assigned clients until the incoming nurse arrives 2. Tape-record a report and leave a cell phone number to call if there are any questions 3. Tell the charge nurse if the impending need to leave and that client coverage is required 4. Write out a report about the clients for the incoming nurse prior to leaving
3. Tell the charge nurse if the impending need to leave and that client coverage is required In a facility with 24 hour care, prior to leaving, an off-going nurse must have another nurse take over the responsibility for the client's care and given an appropriate report for these clients. Leaving clients without these elements can be deemed to be an act of abandonment.
A nurse discontinues patient-controlled-analgesia per the health care provider's prescription, and notes that there is 10 mL of morphine sulfate left in the cartridge. All other nurses on the unit appear busy. What is the most appropriate action by the nurse? 1. Ask unlicensed assistive personnel to witness the wasting of the medication 2. Document that another nurse was not available to waste the medication 3. Wait until another nurse available and then witness the waste together 4. Waste the morphine alone and then show the empty cartridge to the charge nurse
3. Wait until another nurse available and then witness the waste together
Which emergency department client would be allowed to leave against medical advice after the risks are discussed with the primary care provider? 1. 5-year-old client with meningitis whose parent refuses antibiotics 2. Client who tried to commit suicide by taking a handful of acetaminophen an hour ago 3. Client with a urinary tract infection who is disoriented to time and place 4. Client with coffee ground emesis from chronic use of high-dose aspirin
4. Client with coffee ground emesis from chronic use of high-dose aspirin After an explanation of the risks is given, a client must be considered competent in order to leave AMA. A client with suicidal ideation or altered consciousness is not competent. Parents may not refuse lumb-, life-, or organ-saving treatment for a minor child based on their own personal beliefs
The night charge nurse is making assignments for the next shift. Which client is most appropriate to assign to a nurse with less than a year of experience who is floated from the orthopedic unit to the medical unit? 1. Client newly admitted for an evolving ischemic stroke 2. Client newly diagnosed with diabetes mellitus who needs insulin administration teaching 3. Client with exacerbation of chronic obstructive pulmonary disease (COPD) with a new tracheostomy 4. Client with sickle cell crisis who requires frequent intravenous (IV) opioid medication for pain
4. Client with sickle cell crisis who requires frequent intravenous (IV) opioid medication for pain A stable client with the least complex problems and the most clearly defined outcomes is the most appropriate assignment for a float nurse
The client has metastatic cancer, and a living will on record indicates that the client does not want cardiopulmonary or pharmacologic resuscitation. The client is brought to the emergency department with respirations of 4/min and heart rate of 20/min. How should the nurse handle the situation at this time? 1. Ambu bag the client with a bag-valve-mask apparatus 2. Ask the client if the client has had a change of mind 3. Find out who is designated as the client's durable power of attorney for health care 4. Provide comfort measures
4. Provide comfort measures Two common advance directives are a living will (dealing with specific events/issues) and a durable power of attorney for health care (ex. an individual who can make decision on the circumstances in light of the client's wishes). A client's specific wishes as indicates should be honored
A housekeeping employee tells the staff nurse of having a headache and asks for acetaminophen. How should the nurse respond? 1. Ask about liver disease and give acetaminophen from the nurse's personal supply 2. Assess the employee's blood pressure 3. Check for allergies to drugs before giving acetaminophen from hospital stock 4. Refer employee to the employee health provider
4. Refer employee to the employee health provider The nurse should not give medication an employee without a prescription even if it is an over-the-counter drug.
A client was treated in the emergency department 2 days ago. The nurse makes a follow-up call to say that a culture shows that the client needs an antibiotic. The client's spouse answers the phone, says that the client is at work and doing fine, and that the client does not need the antibiotic. Which is a priority action for the nurse? 1. Call the prescription into the client's pharmacy 2. Document the spouse's statement in the client's chart 3. Notify the emergency department physician 4. Request that the spouse tell the client to call back
4. Request that the spouse tell the client to call back A competent adult with decision-making capacity can refuse essential tx; the client's spouse does not have the legal authority. Treatment refusal must include awareness of the risks and benefits